Provider Demographics
NPI:1164708095
Name:HERNANDEZ, AMANDA MAE (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-4515
Mailing Address - Country:US
Mailing Address - Phone:405-601-1154
Mailing Address - Fax:405-601-1183
Practice Address - Street 1:5714 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-4515
Practice Address - Country:US
Practice Address - Phone:405-601-1154
Practice Address - Fax:405-601-1183
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0052603164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse